Vulnerabilities of Arab refugees in primary health care: a scoping review

ABSTRACT OBJECTIVE To map and analyze the vulnerabilities of Arab refugees in the context of primary health care. METHOD Scoping review in which studies published in English, Spanish and Portuguese languages from 2011 onwards were reviewed. The following databases were surveyed: Cochrane, Scopus, Health System Evidence, MedLine-PubMed, CINAHL, Embase, Lilacs, Web of Science, SciELO, NYAM Grey Literature, BVS, Capes Thesis and Dissertation Database, Refworld and Journal of Refugee Studies. Data were analyzed in light of the concept of vulnerability. RESULTS Of the 854 studies identified, 40 articles were held for analysis and extraction of vulnerability indicators in the individual, social and programmatic dimensions. Regarding the individual dimension, the main indicators identified were unemployment, unstable and overcrowded housing, lack of sanitation and access to water, mental disorders, communicable and chronic noncommunicable diseases, etc. In the programmatic dimension, were identified, mainly, health teams with work overload, lack of preparation to deal with cultural and linguistic barriers, and delays in providing care. In relation to the social dimension, lack of access to schools, to information about health programs in the host countries, and to rights, among others, were found. CONCLUSION Vulnerabilities found highlight the disadvantage of refugees regarding health programs, services and system in host countries, in addition to highlighting the deep inequalities that affect this group. It is pointed out the need for programs and policies that promote actions, within the scope of primary health care, which recognize and respond to the health needs of refugees.


INTRODUCTION
In 2019 it was estimated that 275 million people migrated outside the borders of their own countries, meaning that 3.5% of the world's population were international migrants. That figure number has tripled in the last 45 years 1 . Currently, there are about 79.5 million people in forced displacement and, of these, 26 million are refugees 2 , i.e., people who "are out of their home country because of well-founded fear of persecution related to armed conflict, race, religion, nationality, membership of a particular social group or political opinion, or serious and widespread violation of human rights" 3 .
In 2011, due to the so-called Arab Spring and the armed conflict in Syria, the Arab world became the epicenter of the refugee issue. Syria now has the largest forcibly displaced population in the world. Of its population of 13.5 million in 2019, 6.7 million of them are refugees. Iraq has about 3.3 million people in this situation, and Palestine, 5.5 million 2 . Lebanon has the highest concentration of refugees in the world in relation to the general population (156/1,000) 4 , which worsens health conditions in the country, noting that most refugees come from Syria [5][6][7][8] .
Global refugee trends also echo in Brazil. Since the beginning of the conflict in Syria, 3,772 people have requested refuge in the country 9 and, among the Arabs, Syria, Palestine, Lebanon and Iraq are the countries of origin that had their refugee status most often recognized in Brazil 10 .
The status of refugee is per se an element of vulnerability considering forced migration, and because it represents a serious and widespread violation of human rights 11 . This article aims at mapping and reviewing the elements of health vulnerability of Arab refugees in the scope of primary health care (PHC).

Stage III: Study selection.
Following were the inclusion criteria: subjects of the studies were Arab, Syrian, Palestinian, Iraqi, and Lebanese refugees in the condition resulting from forced migration, because they are the nationalities that most had the refugee status recognized in Brazil 10 ; studies that made it possible to identify constitutive elements of the concept of vulnerability; studies that presented elements of vulnerability in any of the four phases of refuge (origin, transit, destination, and return); studies that had PHC as a setting.
The following studies were excluded: on voluntary migration (non-forced displacement and economic migration); did not bring original/primary data (article of opinion, experience reports, literature reviews). We did not delimit the length of migration of the studies' subjects.
We consider vulnerability "a set of individual and collective aspects related to the greater susceptibility of individuals and communities to an illness or injury and, inseparably, the lower availability of resources for their protection" 13 . We also consider the three interdependent, inextricable, and synergistic dimensions of the concept: individual, programmatic, and social 13 . The individual dimension takes as its starting point aspects of the way of living that may contribute to the exposure to a given health problem, or aspects that may protect against certain problems. The programmatic dimension integrates the efforts of institutional programs, especially health programs. The social dimension covers all the contextual elements related to life in society: the legal, political, and ideological structure, governmental guidelines related to health and social issues, social relations, and religious beliefs, among others 14 .
After identifying the articles in databases, duplicates were excluded, followed by analysis by title; by abstract; and by the full text (Figure).

Figure.
Flow diagram on the process of selecting studies for Scope Reviews, inspired by PRISMA by Moher et al. 15 .
Articles identified by searching the databases (n = 854). We designed a form to extract and organize the following data: author, year of publication, country of study, country of origin and destination of refugees, objectives, type and population of the study, sample size, study setting, elements of vulnerability in the individual, programmatic and social dimensions, as indicators of stage V (Tables 2, 3 and 4).
Stage V: Conference, summary, and reporting of results.
Programmatic dimension: 1) Health Policies; 2) Actions of the Health Programs; 3) Access to Health Services.

RESULTS
After selection, 40 studies remained for analysis and data extraction (Figure). In the process of reviewing the production of studies by continent it was found that Asia produced 15 studies (37.5%), North America 12 (30%), Europe 12 (30%), and Oceania 1 (2.5%). No original study published in a Brazilian or Latin American journal was found. No relevant grey literature was identified either. Studies on Syrians were prevalent (18: 45%), followed by Palestinians (13: 32%) and Iraqis (2: 5%). The predominance of studies with Syrians is justified by the historical interval studied (from 2011 onwards). We did not identify studies with Lebanese refugees. Most of the studies (30) were conducted with refugees in the destination countries: Jordan (17 studies: 42%); Lebanon (9: 22%); Syria (3: 7.5%); in urban areas (29: 72%). Most of the studies (31: 77%) were quantitative.

I -Syrian Refugees
Twenty-two studies were found (Table 2)   . Regarding the elements of individual vulnerability, the morbidities that stood out most were: mental disorders, overweight/obesity, eating disorders, tuberculosis, chronic noncommunicable diseases, and sexually transmitted infections. Syrian refugees are about 10 times more susceptible than the host country population to mental health problems (52%) 32 and post-traumatic stress disorder (PTSD) was present in almost half of the cases 28 , strongly associated with exposure to war 32 and eating disorders 28 . Anxiety and depression were also highly prevalent (40.3% and 47.7%, respectively). Most of the refugees who developed anxiety and depression in the country of destination did not have it in the country of origin 36 . The conditions that may result from adverse experiences at the destination (exposure to trauma, loss of family members, in relation to social status and material goods, chronic deprivation in basic needs); in the transition (unsafe means of transportation: risk at sea crossing, of exploitation by smugglers), in the camps (overcrowding, uncertainty about the future, and severe lack of resources), and after resettlement (unfamiliarity with the new context, language barriers, poverty, unemployment, lack of support, discrimination) 36 . Greater difficulty in access to medicines than local population.
Chronic noncommunicable diseases, especially diabetes (DM) and hypertension (SAH) were mentioned in eight studies 22,24,27,31,34,35,38,54 , and the prevalence of DM was higher than in the local population; in women, it was almost twice as high, as was the risk for the disease 54 . The higher prevalence of DM refers mainly to individuals with a relatively long-lasting history of migration. There is an increased risk for DM about six months after arrival, and it is accentuated after four years of migration 54 . Refugees may face an accumulation of risk factors for DM: increased genetic susceptibility, low birth weight, exposure to childhood hunger, major socioeconomic change, acculturation stress, and distinct lifestyles in the host country. The refuge seekers with PTSD had almost 1.5 times greater chance of being diagnosed with DM compared to others in the same condition 54 . Also, fasting blood glucose levels above 120 mg/dl were found in 57.9% of the refugees with DM 34 .
Approximately 73.9% of the refugees had a family member with a chronic disease (SAH: 25.2% of patients) 37 . Respiratory diseases were mentioned in four studies 22,25,27,31 .
In Lebanon, 89.1% of Syrian refugees in the study sample sought PHC due to chronic respiratory disease 31 . Refugees experience exacerbation of respiratory diseases due to the desert climate of some refugee camps 22 . Tuberculosis (TB) was noted in three studies 27,30,33 . About 11.8% of Syrian children (aged 7 months to 16 years) in Australia had tuberculosis 33 . Tuberculosis treatment success was lower among Syrian refugees in Turkey (63.6% of cases) than among local population (88.8%). The context of war is directly related to the increased prevalence of the disease. In Syria, before the beginning of the conflict, the incidence was 23 cases/100,000 inhabitants, and after the conflict it increased to 51 cases/100,000 30 . During the civil war, the main problems in relation to tuberculosis are related to diagnosis, treatment, and prevention of the disease, access to health services and drug supply, increased reactivation, transmission, due to living conditions: crowding, nutrition, shortage of medicines and health personnel, and psychological stress 30 . Infectious/transmissible diseases were mentioned in three studies 25,26,38 , and in a study conducted in Lebanon with 1,218 Syrian refugees, these diseases were prevalent (40.5%) 38 .
The vulnerability indicator "work" was found in three studies 27,28,37 . The unemployment rate among Syrian refugees was 84.2% in the study population 28 . The indicator "beliefs and values" concerning the disease was found in four studies 23,28,29,35 . Only 58% of Syrian women in Lebanon used some method of contraception; the birth rate is high, noting that women over 40 years old reported having between 8 and 12 children 23 .
The indicator "living conditions" was found in five studies 17,20,22,32,56 , disclosing insecurity, overcrowded housing, and absence of toilets in refuge camps 17,22 . More than half, 54.3%, reported the use of extreme mechanisms to face food insecurity (reduction of the portion; of the number of meals taken/day; reduced consumption by adults to allow feeding the children) 20 .
Regarding the programmatic dimension, the indicator "access to health services" was the most found in the studies (8) [21][22][23][24]26,27,37,38 , followed by the indicator "health policies" (7) [22][23][24]27,32,34,56 and the indicator "program actions" (6) 21,29-31,33,34 . Regarding access to health services, 60% of Syrian pregnant women in Turkey faced difficulties due to language and waiting time for care 37 . The lack of medical professionals and the cost 21,23,24,38 were reported as barriers to access for perinatal care 22 . In Greece, a study found that 50% of consultations in medical specialties were performed by national and international NGOs, unveiling a transfer of responsibility from the local government to these entities in providing access to health services. The main causes of referrals are obstetric/gynecological (35%) care, pediatric care (15%), and to obtain prescription drugs not available in PHC (16%) 26 .
Regarding the "Health Policies" indicator, the lack of a universal and free system stands out 22,27,56 . In a study with Syrian refugees in Jordan, 80% of respondents reported the need to pay some amount for health care in PHC 22 .
As for the indicator "actions of health programs", included in the programmatic dimension, it is evident the difficulty of PHC teams in interacting with Syrian refugees 34 , especially in Lebanon. About 40% of respondents in Jordan reported discrimination by the healthcare team 21 . It should be considered that health professionals suffer the tension resulting from structural processes and fragile local governance, exposing them to the extremes of lack of human and material resources, and especially of knowledge about the refugee's health issue 56 .
In the social dimension, the indicator "access to education" 21,23,24,27,28,32,33,35,37,56 was observed, and four of these studies 21,24,28,37 specifically approach with the difficulty of access to studies by the adult refugee population. In one of the studies, 42% had not completed any formal education 35 . A high rate (55%) of school dropouts by children was also found 21 .
In Australia, a study reported that 25% of Syrian children were out of school even after three months in the country, and 67.9% had missed at least one school year before getting to the country 33 .
The indicator "access to information" was also observed 21,23,24,35,37 , identifying lack of information regarding the availability of family planning services in the Basic Healthcare Unit (Unidade Básica de Saúde, UBS) 21,23 . One of the studies with Syrian refugees in Lebanon pointed out that 61% of the respondents were unaware of the availability of services 21 .
On the other hand, international and local NGOs provide care for Syrian women through PHC, offering family planning free of charge (insertion of IUDs, contraceptive pills, and male condoms), as well as consultation with a midwife or obstetrician/gynecologist, and laboratory tests 21 .
The marker "migration" was found in three studies 23,37,56 . The pattern of migration flow affects the adherence to treatment of cardiovascular diseases in Syrian refugees arriving in Jordan, because during the trip they are unable to acquire the medicines 29 . In Jordan, a study indicated that 50% of the Syrians had concrete plans to leave the country, mainly towards Europe, due to the lack of access to fundamental rights, including education, health, work, and food. Part of one statement stands out: "a quick death at sea is better than dying a thousand deaths every day" 56 . Table 3 summarizes the 14 studies dealing with this refugee population [39][40][41][42][43][44][45][46][47][48][49][50][51][52] . Diabetes was the most noticeable disease 40,42,43,45,48,50,52 . In a study of 2,851 Palestinians aged up to 60 years and allocated in Jordan, the association between DM and SAH reaches 77% of the sample 50 , and obesity is one of the main additional associated risk factors. In another study, 59% of diabetic patients were obese (BMI > 30), 69% were women 52 . One of the surveys of Palestinian refugees in Jordan showed an association between DM and SAH in 81% of the sample, affecting all age groups: 21% were younger than 5 years old, 36% between five and 10 years old, and 43% were older than 10 years 42 . Hypertension also stands out among the main morbidities 42,44,45,48,50,52 , with increased prevalence from 2008 to 2012 among Palestinian refugees in Jordan (two million), ranging from 13.8% to 16.3% of the patients seen. Noteworthy are patients with uncontrolled hypertension, which, in the same period, ranged from 31.5% to 45.9% of patients 44 .

II -Palestinian Refugees
Regarding mental disorders, depression stands out (28%) 47,49 and among infectious diseases, diarrhea draws attention. One of the studies points out that 20.3% were infected with Giardia duodenalis, related to low water quality. The lack of access to free public drinking water was associated with infectious diarrhea, highlighting that 62.4% had to buy water 46 .
One of the studies, conducted in Jordan, Lebanon, Syria, Gaza, and the West Bank, identified the main causes of infant death in the first year of life: low weight and prematurity (30%), congenital malformation (22%), and respiratory tract infection (13.4%) 41 . The indicator "work" was found in two studies 39,46 . The unemployment rate reaches 90% among Palestinian refugees in Jordan 39 . Even in the Palestinian territory itself, the majority of those who found employment had informal working relationships 46 .
The indicator "living conditions" was verified in two studies 32,46 . Palestinians live in the refugee camp for an average of 16.2 years, reaching up to 27.5 years, a much longer period than the Syrians. In this context, they live without public sanitation services, the houses/tents/containers are insufficient, and there is overcrowding 32 .
Regarding Programmatic Vulnerability, the indicator "actions of health programs" 40,[41][42][43]46,[49][50][51] was predominant. It is noteworthy the report of teams and patients that have mental and physical overload at work 47 . It is relevant to mention the loss of follow-up in the treatment of DM and SAH 40,42,48,50 . The increase in the migratory flow directly impacts the supply of services. In Jordan, of the patients who sought the PHC, 58% could not have their postprandial glycaemia measured 50 . Among patients with hypertension, 37% did not have their blood pressure recorded 50 , and 38% missed the scheduled return visit 40 .
The second most common indicator refers to "health policies" 43,44,47 mainly focused on drug intervention, with repercussions on spending on hypertension 44 . Only in 2011 did the UN introduce family health teams in Syria, Lebanon, and Jordan; previously, interventions were limited to medical centrality 47 .
Two studies addressed the Programmatic Vulnerability indicator "access to health services" 39,41 . In one, the majority (88%) of Palestinian refugees in Jordan reported waiting for long hours at the health facility, which resulted in doubling the risk of self-medication with antibiotics 39 . In the Gaza Strip and West Bank, poor access to PHC services was the main determinant of neonatal death 41 .
Regarding the elements of social vulnerability, the indicator most cited was "access to education" 32,43,49 . One of the studies points out that Palestinian refugees without any level of education in Lebanon accounted for 15.5% of the sample, almost double the local Lebanese population with the same level of education (8%) 32 . Low educational level among pregnant Palestinian refugees in the Gaza Strip was a factor associated with predisposition to gestational diabetes 43 . Studies confirm social exclusion in relation to participation in the economy with informal underemployment among this group of refugees. Legal restrictions in the host countries, such as Lebanon, corroborate the stigma about Palestinians. Table 4 summarizes the five studies about this refugee population [53][54][55][56][57] . The prevalence of infectious diseases, malnutrition, mental disorders, and diabetes stands out. In adults, the prevalence of DM was higher than in the local population, and almost twice as high in women 54 . Among children, we highlight vitamin D deficit; growth and nutritional problems; latent tuberculosis; neurological/metabolic and learning/behavioral disorders; delayed development; as well as exposure to trauma and separation from a family member 33,53,54 .

III -Iraqi Refugees
"Work" was another indicator checked 53,56,57 . In a study with Iraqi refugees in the United States, unemployment reached 90% 53 , with a predominance of informal work. The majority (61%) of Iraqi refugees in Syria hold casual jobs in the service sector (commerce), and only 12% have formal and stable jobs. Hard work is significant, with an average of 59 hours a week. There were also reports of child labor, underemployment, and payment for labor far below market rates, in addition to lack of payment after providing services 56 .
Regarding the "beliefs and values" indicator, the non-adherence to treatment for latent tuberculosis stands out. The lack of symptoms leads to the belief that treatment is unnecessary 53 .
Regarding the programmatic dimension of vulnerability, the indicator "actions of health programs" 33,53,55 stands out, mainly in the form of long waiting hours (in American health services), as well as lack of translator and empathy by the health team 53 . In one study, only 1.8% of the children had a complete health evaluation according to the protocol recommended for refugees 33 .
Regarding "access to healthcare services" 33,55,57 , difficulty to perform tuberculin skin test was observed among Iraqi refugees in the Australian PHC; and difficulty of access to health care in more crowded European borders 55 . Moreover, many patients did not use contraceptive methods, and 82% could not access them because they were unaware of the family planning services available 57 .
As for the "health policies" indicator, one study mentions that Jordan revoked the free access of Iraqi refugees to health care and fundamental rights, a step backwards in this free health care offer, motivated by the discourse of financial deficit 56 .
The most common indicator regarding the social dimension of vulnerability is "access to education" 33,49,56,57 . About 32% of Iraqi children in Australia missed three or more years of school in the pre-arrival period 33 . Children have difficulty enrolling in school because they lack an official residential address in Jordan 56 . Refugees with less education were more susceptible to mental illness 49 , poverty, and about twice as susceptible to a per capita income below $1/day 57 . The "migration" indicator brings up the sense of constant threat, for fear of expulsion by the government, experienced by Iraqi refugees in Jordan 56 .

DISCUSSION
All dimensions of vulnerability were present in the studies of our sample. The bibliometric findings indicate that the predominance (77%) of quantitative studies may result in partial assessments of the life experiences of the populations studied. Studies conducted entirely in refugee camps and studies with significant samples in Brazil and Latin America were also scarce (8%), in addition to the scarcity of multicenter studies. There was no mention in the studies or comparative analysis regarding the difference in access to health care between refugees and asylum seekers. There was no study on comparative analysis of health vulnerabilities between Arab refugees and refugees of other nationalities. It is worth noting that "refugees" and "asylum seekers" are part of the same forced migration bloc; however, asylum seekers are only waiting for a bureaucratic step for their recognition as refugees in the host country.
Among Syrians, there is a lack of studies on the health needs of specific groups such as children, adolescents and women, and no studies on the health needs of female Palestinian refugee in PHC have been identified. Although Turkey is one of the main destination routes of Syrians, it was observed in our sample scarcity of studies (5%) related to the context of PHC in that host country.
Regarding the dimensions of vulnerability, the individual dimension reveals the presence of chronic and infectious diseases, besides the significant presence of mental disorders. These are corroborated by and attributed to traumatic experiences, even before forced migration: violence, abuse, and uncertainty about the future 58 . Despite the significance of mental disorders, this review and other studies point to a new challenge regarding the escalation of NCDs, with repercussions on the health system of the host countries in areas of conflict, especially Jordan, Lebanon, and Turkey, and increased spending on treatment, especially for DM and hypertension 22,24,27,31,34,35,38,44,54,59 . It is noteworthy that in the studies analyzed in this review, PHC played a central role in providing access to health systems in countries neighboring the conflict zones 47,60 .
Findings regarding women's health are supported by a study that identified gestational diabetes, stillbirths, and children with low birth weight, in addition to inadequate prenatal care 61 . Congenital malformation was associated with early pregnancy and consanguineous marriage in Palestinian refugee women 41 . Refugee children suffer from conditions resulting from inadequate nutrition, malnutrition, micronutrient deficiencies, as well as oral health needs and infectious diseases, in addition to the consequences of exposure to war conflicts, violence, and xenophobia, and developmental delays and failures in schooling, among others 62 . Recent findings show evident inequality in vaccination coverage among refugee children when compared to the general population: they are three times less likely to be vaccinated against preventable infections, especially measles, tetanus, and meningitis C 63 . The difficulty in access to vaccines, and low vaccination coverage upon arrival in the host countries are evident in this study 33 .
Regarding the programmatic dimension, fragmentation of policies, programs, services, and health teams stands out. The PHC teams that work in the front line, in regions of large migration flows, have difficulties in dealing with refugees and work overload, besides absenteeism 47 . Another study supports and points out this phenomenon as a consequence of conflicts and war, which impact the entire local health system and that of neighboring countries, reducing the supply and quality of services, as well as promoting an exodus of health professionals. As a result, exclusionary policies that restrict and bureaucratize access to PHC have been adopted, such as more stringent document requirements for the acquisition of housing and food subsidies, end of gratuity, and beginning of charging for PHC services 64 . There is inequality in access, especially for refugees with lower educational level, who are more vulnerable among the vulnerable and depend on assistance from local governments 17,24,27,[32][33][34][35][36][37] . A cross-sectional study of 400 Syrian refugees in Canada points out that refugees accessing public or local government-funded health care compared to refugees accessing private or privately funded health care report more unmet health needs and more complex medical conditions, and are almost three times more likely (OR = 2.84; 95%CI: 1. 55-5.20) to not have their health needs met. Of those refugees, only 58% report having a family doctor of referral 65 . There are reports of a growing need for refugees in Lebanon and Jordan to pay for PHC services 22,27,56 . Although refugees disburse less than the local population, it is noteworthy that this situation is added with high unemployment, and low income (less than two dollars/day among refugees) 22 . The UN/ UNHCR offers a program of income distribution and financial assistance for Syrian refugees in Jordan, for example, but only 23,000 families have access 22 to it. It is a very restricted number considering the more than 676,300 Syrian refugees under UN protection in that country 4 . In Jordan, a biometric personal identification card is required for access to health and nutritional support, but there are a number of requirements to obtain it 17,22 .
As a result, many Syrians have been forced to further reduce their food intake, stop seeking health care, and take children out of school to offset costs or generate additional income through child labor 17 . The average number of meals for adult Syrian refugees in Lebanon was 1.8 meals/day, and among children, 2.3 meals/day 17 .
As for the main destination and host countries, Jordan, Lebanon and Syria, there is no explicit information on the websites of their respective Ministries of Health about public health policies for refugees. Lebanon is not a signatory to the 1951 Refugee Convention and, in this sense, there is no domestic law addressing refugee needs in the country 68 . There are records that Palestinians and Syrians suffer from marginalization and discrimination as a result of policies that deny access to basic rights such as housing, work, education and health care 69 . The United Nations Relief and Works Agency (UNRWA) has suffered major budget cuts, and its largest donor, the United States, has cut funding 69 . However, there is controversy about governmental actions regarding refugees in this country, pointing out the existence of primary health care provision, which includes consultations, lab and diagnostic testing for groups previously defined as vulnerable, offered at a reduced cost to residents 69 . Vaccination, two ultrasound examinations for pregnant women, and medication for acute and chronic conditions are free of charge 69 .
In Jordan, it is noted that rental housing is affordable, and housing in settlements is offered in exchange for work on local farms 69 . The reduced offer of labor determines the need to work or get married, which leads to dropping out school 69 . To mitigate such situations, the government has implemented a program: "Cash+", which includes social protection interventions for families in vulnerable situations, who get unconditional monthly cash transfer per child. Mental health programs are also offered in integration with primary health care services 69 . Refugees in camps have free access to health care, subsidized by the government and international agencies. Refugees registered with the Ministry of Interior in Jordan have access to healthcare and government benefits, in the same way as uninsured Jordanians. However, it is noteworthy that refugees have financial burden to afford with consultations and medication in private health services 70 .
As for the social dimension of vulnerabilities, inequality was evidenced in the access to education, information, decent work, besides prejudice/stigma, and difficulties of participation in collective actions and consequent difficulty of integration in the host countries 17,[21][22][23][24]27,32,33,35,37,43,49 . Indeed, social disconnection and comorbidities are prevalent, and lack of engagement in the community was associated with unfavorable health outcomes, especially in relation to mental health. Difficult social integration persisted for three or more decades after arrival in the US, constituting a health risk factor 66 . Other findings point to the social exclusion of refugees as a consequence of structural inequalities, including marginalizing policies, and lack of social security. The lack of basic services in the host countries leads to disputes between local population and refugees, besides the progressive degradation of living conditions 67 .
Regarding the recommendations for policies and practices in PHC, there is a need for screening cases and strengthening programs and policies, especially in the field of mental health, with Syrian and Palestinian refugees 36 . Evidence suggests the indication of diabetes screening for newly arrived refugees older than 35 years 54 . Healthcare providers should be aware of the high risk for diabetes among Syrian, Palestinian, and Iraqi refugees 54 . Moreover, there is a need to strengthen women's health programs, aiming at early identification of gestational diabetes, including in the postpartum period, especially among Palestinian refugees 43 . In order to improve adherence and success in the treatment of tuberculosis among refugees, there is a need for a specific program for the group mainly addressing beliefs about the disease and the treatment of latent tuberculosis 30 .
One of the limitations of this research is the restriction to studies with subjects who forcibly migrated; therefore, the vulnerabilities mapped are not generalizable to the bloc of non-forced migrations. The vulnerability elements found do not encompass the context of the 22 Arab countries in the world, being restricted to Syrians, Palestinians, and Iraqis. It is also important to point out the heterogeneity of the methods used, which made the process of data extraction difficult, even when the study dealt with refugees from more than one country of Arab origin, because some did not separate outcomes by nationality, which made the extraction and synthesis of this review difficult.

CONCLUSION
The Asian continent, the Middle East, followed by North America and the European Union produced the most studies with Arab refugees in the context of PHC. There is an evident gap in the production of knowledge about this subject in the Latin American continent, and none of the studies used the concept of vulnerability, as adopted in this scoping review.
Arab refugees experience contexts of high vulnerability, placing them in profound inequality and disadvantage before the health programs, services and system of the host country. Therefore, there is a need for programs and policies that consider the elements of vulnerability and promote actions in PHC in order to respond to the health needs of refugees. It should be considered that the clash of forces between countries, mainly due to economic interests, causes destructive repercussions to populations, imposing its urgent overcoming and intransigence, besides the repudiation of actions that show social injustice. We defend the need for policies of inclusion, social justice and dignified living conditions for all people in situations of refuge, rejecting all kinds of stigmatizing attitudes and practices that show dehumanization.